Influenza Self-Reporting

Instructions
Vaccination details

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When can I self-report?
Please self-report as soon as possible after receiving your influenza vaccination.

You are also required to self-report if you decline vaccination. You will be expected to wear a mask in patient care areas for the duration of the influenza season.

What do I need to provide?

Basic contact and work information for us to identify and contact you (if needed)
Date and location of your vaccination
Certification that you are vaccinated or declining vaccination

By self-reporting, you agree to our terms and conditions, data and cookie policies.

Vaccination Status

Please select one of the following:*

I certify that I have received my influenza vaccine. info_outline

I certify that I am declining vaccination and understand I am expected to wear a mask in patient care areas for the duration of the influenza season. info_outline

Vaccination date*

Who immunized you?*

info_outline

Worker information

Health organization*

info_outline

Employee number -OR- Billing number*

info_outline

Personal and contact information info_outline

First name*

Last name*

Date of birth*

Home postal code (A1A 1A1)*

Phone # (123-456-7890)* info_outline

Work email* info_outline